*We are grateful to the Department of Health and Human Services for their funding and support of this work. **We acknowledge and thank Clare O’Callaghan and Associate Professor Natasha Michael at Cabrini Health, for acting as our research partners in co-facilitating the focus groups and identifying themes. Parliament of Victoria Inquiry by Legal and Social Issues Committee into end of life care Submission from Health Issues Centre (HIC), Melbourne HIC contacts – Danny Vadasz (CEO) E: and Emma Sayers (Project Manager) E: 31 July 2015 Background Health Issues Centre welcomes the opportunity to inform the work of the Legislative Council’s Legal and Social Issues Committee in relation to end of life choices. Using the valuable and unique insights of consumers as health service users, carers and citizens, Health Issues Centre works towards a health system with better health outcomes and experiences for all. HIC actively supports the involvement of consumers and the community in shaping policy and practice around end of life care. Advance care planning is one mechanism that has been created to assist people to exercise their preferences for the way they want to manage their end of life. In the first half of 2015 Health Issues Centre conducted a series of consumer focus groups to gauge community awareness, attitudes and experience in relation to advance care planning. * Members of the community targeted were – People aged 60 or over People living with a chronic or serious illness People caring for someone with a chronic or serious illness (other than dementia) People caring for someone living with dementia People with ageing parents Eight in-depth, semi-structured discussions were conducted with a total of fifty participants in metropolitan Melbourne.** With participant permission, discussions were recorded and transcribed. Transcripts were reviewed to identify key themes which were analysed in the context of the existing literature on consumer experience of advance care planning. Conclusions have been tested and refined in discussion with key informants from the health service and community sectors. Introduction Victorians are fortunate to live in a country where most of us now die at an older age. Due in part to advances in medical treatment and technology, about two-thirds of Australians now die between seventy-five and ninety-five years of age. (1) We are in the enviable Submission 693
Transcript
*We are grateful to the Department of Health and Human Services for their funding and support of this work. **We acknowledge and thank Clare O’Callaghan and Associate Professor Natasha Michael at Cabrini Health, for acting as our research partners in co-facilitating the focus groups and identifying themes.
Parliament of Victoria
Inquiry by Legal and Social Issues Committee into end of life care
Submission from Health Issues Centre (HIC), Melbourne
HIC contacts – Danny Vadasz (CEO) E: and
Emma Sayers (Project Manager) E:
31 July 2015
Background
Health Issues Centre welcomes the opportunity to inform the work of the Legislative
Council’s Legal and Social Issues Committee in relation to end of life choices.
Using the valuable and unique insights of consumers as health service users, carers and
citizens, Health Issues Centre works towards a health system with better health outcomes
and experiences for all. HIC actively supports the involvement of consumers and the
community in shaping policy and practice around end of life care.
Advance care planning is one mechanism that has been created to assist people to exercise
their preferences for the way they want to manage their end of life. In the first half of 2015
Health Issues Centre conducted a series of consumer focus groups to gauge community
awareness, attitudes and experience in relation to advance care planning.* Members of the
community targeted were –
People aged 60 or over
People living with a chronic or serious illness
People caring for someone with a chronic or serious illness (other than dementia)
People caring for someone living with dementia
People with ageing parents
Eight in-depth, semi-structured discussions were conducted with a total of fifty participants
in metropolitan Melbourne.** With participant permission, discussions were recorded and
transcribed. Transcripts were reviewed to identify key themes which were analysed in the
context of the existing literature on consumer experience of advance care planning.
Conclusions have been tested and refined in discussion with key informants from the health
service and community sectors.
Introduction
Victorians are fortunate to live in a country where most of us now die at an older age. Due
in part to advances in medical treatment and technology, about two-thirds of Australians
now die between seventy-five and ninety-five years of age. (1) We are in the enviable
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position of having an older population who aspire to be actively involved in the social,
cultural, and economic activities in their local communities. This aspiration is not always
well-supported by attitudes and structures that associate ageing with decline and
dependency. This includes the health system, where older people have been referred to as
“bed stoppers”; in danger of being seen as “cast-offs” who’ve “snuck (in) for a bit of
inappropriate, grudgingly given treatment”. (2)
At the same time, it is a reality that with longer life comes the increased likelihood of
chronic disease and disability. The end of life trajectory will depend on the condition(s), but
for at least some Victorians this will mean slower decline with sporadic episodes of serious
illness, or a long period of comparatively low quality of life. (3)
The older Victorians we spoke with did not want to be ‘written off’; nor did they want to be
‘kept alive’ by medication or technological intervention with little or no quality of life.
Conversations need to be led within both the community and the health professions that
address fears regarding technology-driven ‘overtreatment’ and ageism-driven
‘undertreatment’. The common use of battle metaphors and the lauding of people who are
‘fighters’ can help keep fear at bay, but also drown out a much-needed conversation around
dying and the use of intervention at the end of life.
Advance care directives (ACD) have been heralded by some as the solution, with people able
to give instructions for their future health care, stating what medical treatment they would
like (or not like) in the event they are unable to make decisions for themselves. For the
purposes of this submission, an advance care directive is defined as a written document
recognised by common law or authorised by legislation that records a person’s directions
about medical care and treatment refusals.
The ACD concept is appealing in its apparent simplicity but like most complex issues, end of
life care is shaped by multiple and interlinking factors. In this paper, we argue for the value
of end of life and advance care planning conversations whilst cautioning against the
overpromise of advance care directives as a bioethical “magic bullet”. (4) Community
attitudes, health and legal literacy, professional cultures, communication skills and service
availability are all factors that need to be addressed. A summary of key findings can be
found at Appendix A.
A note about euthanasia
The basis for fears of burdensome, disrespectful or inadequate care at the end of life
requires further investigation. This includes cases where symptom management, sometimes
referred to as “comfort” care, is not able to achieve comfort. Policymakers need to be clear
on the scale and nature of intractable cases and the capacity of law to help or hinder their
management. The choice to die should not be driven by a perceived need to avoid poor or
inadequate care. (5) Investment in a multi-pronged approach to service improvement should
be prioritised.
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Discussion
The challenge of getting the care you want at the end of life
By definition, an advance care directive relates to future health care in circumstances of
incapacity. A person can indicate his/her consent or refusal to particular medical
treatments. The usual legal (and ethical) standard that applies regarding patient
involvement in medical decision making is that of informed consent. (6) This requires that
the person be informed of –
The diagnosis and likely outcome (prognosis) of the condition
An explanation of the recommended treatment
The risks of the procedure and common side effects
Possible complications
Any other options for treatment and their probability of success.
Clearly there are inherent limitations in applying this standard in relation to future
decisions. If, as some commentators suggest, a person ideally completes an ACD at a time
prior to a serious health threat, the specific diagnosis is not yet known. More common end
of life trajectories can be anticipated in general terms but remain hypothetical and lack
context. Human beings are typically not good at assessing what it would be like to
experience different hypothetical states of health. People are often wrong when they try to
conceive their future feelings; we tend to focus on our current feelings – and thus fears –
about it. (7) Thus people are likely to need support picturing their future ‘nearing end of life’
self.
End of life intervention options can be anticipated and these are frequently listed on ACDs
(e.g., CPR, ventilation, feeding tube). However, to meaningfully consent or refuse such
procedures the person needs to understand the nature of the intervention, the risks,
common side effects, the probability of success, the consequences of not intervening and
any other options. Some treatment interventions have low rates of success and sometimes
the burdens may outweigh the attempt at benefit. Providing a realistic picture of the pros
and cons of available treatment and intervention ‘choices’ can trigger insight that
sometimes the ‘best’ care may be to stop intervening. The ethical nature of the choice
needs to be clear - it’s not a choice between dying and the restoration of health; it’s the
choice between a ‘better’ or ‘worse’ death. For the person the question will be - how is the
treatment/intervention going to support the aspects of life that I value? (8)
For a person with little or no knowledge regarding the nature or impact of common end of
life treatments/interventions, informed decision making is not possible. It cannot be
assumed that a person completing an ACD is able to source that information or knows what
questions to ask to elicit the information they need. Thus, two opportunities to improve
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health literacy in the community are clear – people need accessible information regarding
common end of life treatments and their success rates; they also need to be supported to
ask questions regarding any choices that are available and the pros and cons of each choice.
Just grasping the two ideas that you have a choice and that not all treatment is beneficial
may be new for some. (9)
Those who recognise that not planning may lead to increased future discomfort are more
receptive to information. (10) For example, the daughter who starts to notice functional
decline in her parent; the man who witnesses the suffering of his brother, who he believes
had “a bad death”. Given an opening, these are people who may welcome a conversation.
In an advance care directive, meaningful instructions regarding treatment options are
dependent on both the options available and your understanding of those options. If there
are options you don’t know you have or options you think you have that aren’t actually
available, your directive is of limited value. If you think that care stops when acute
intervention stops, you may continue for fear of abandonment, not because intervention is
your ‘choice’. If you want to die in the community, but the services required to support that
choice aren’t available, then that’s not a real option. Just as we want to avoid costly
interventionist treatment of no benefit, if people elect the palliative care alternative, we
have to be able to deliver it or the ‘choice’ implied by the advance care directive is rendered
a false promise. Recent reviews report that sufficient palliative care is often not available.
The 2009 report from The National Health and Hospitals Reform Commission concluded –
“we cannot in good faith promise patients at the end of their life access to care that is
customised to preferences and reliably delivers good symptom control. Our health system
can do better”. (11)
Investment in palliative care services is required if the promise of choice is to be made real.
Following a specific diagnosis, a person with capacity has more of a context in which to
consider intervention options. If the clinical team are aware of the likely trajectory, and can
recognise symptoms of decline, they are in position to discuss goals of treatment. What
aspects of life does the person value most? Why do they value them? What are they
prepared to sacrifice in a trade off? (12) Clinicians have a key role to play in assisting a person
Community members won’t engage in advance care planning
conversations unless they understand why it’s important. Increased
knowledge regarding medical intervention during the dying
process, the right to ask questions and discuss options is key to
this understanding.
The capacity to choose palliative care over acute or intensive
intervention relies in part on access to services. Appropriate
investment in patient-centred palliative care needs to be
prioritised.
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to translate their values and priorities into specific treatment decisions. For example, if
independence is valued, is this treatment likely to have an impact on my capacity to look
after myself? If it means I’ll need assistance, is it support at a level my carer or home
services can provide or will 24-hour care be required? What will be the costs associated
with that care?
For this to happen effectively, again assumptions by the health professional need to be
avoided:
‘If I discuss goals of treatment with the patient, they will become upset and lose hope’.
The patient may become emotional but that is not a reason, in and of itself, not to have the conversation. People may move back and forth between acceptance and denial, both strategies to cope with illness, without losing hope. (13) Emotion is normal and to be expected. Acknowledging emotion may be a helpful step in establishing the trust needed to engage in shared decision-making. (14) As trust goes up, fear may go down. Given the amount of fear that exists around the end of life experience, the importance of trust should not be underestimated.
‘This person is over ‘X’ years, they wouldn’t want ‘Y’ intervention to extend their life’. As noted earlier, whilst older people may be concerned about being “kept alive” with no
quality of life, they may be equally concerned about being “written off” as an older person
of no value. A person’s attitude will be affected by their previous medical history and life
experience, or that of their close family. Someone with a long term chronic illness who has
survived numerous acute episodes may identify as a survivor whose life has depended on a
philosophy of ‘never giving up’. Another person may have accommodated limitations by
redeploying their attention to think about domains of life other than health, such as
personal relationships. (15) Definitions of ‘life worth living’ are subjective, are shaped by
health status and life experience, and may change over time. Finding themselves in the
actual situation, patients may rate their health status more positively than they did in the
hypothetical. If a person has capacity, why assume an answer when you can ask?
These conversations may be less confronting in the context of prior ‘priming’. In fifty to
seventy per cent of deaths, death is predictable and expected. (16) Most patients do not
move from ‘capacity’ to ‘no capacity’ overnight. Changes in condition and treatment
response throughout the illness course may cause treatment intent to shift from curative to
symptom management. As clinical teams shift their goals, they need to take patients and
families with them; it may be a process of adjusting and readjusting expectations, one
needing to be underpinned by information and support. Progressive conversations mean
that even when it gets to the stage that the doctor can no longer ask the patient what s/he
Patients should be asked about their goals for treatment. Health
professionals need to assist the person to translate their values
and priorities into specific treatment decisions. Definitions of a ‘life
not worth living’ need to be explored, not assumed. The value of
efforts to build trust cannot be overestimated.
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wants, prior conversations with the person regarding their values and priorities may provide
useful guidance.
These conversations may be challenging for professionals and require a sense of self-
efficacy. A clinician’s sense of self-efficacy is impacted by their education, training and
experience. It is also influenced by the cultural climates within which the person operates
and the sense of security (or not) those climates provide. In end of life care, clinicians are
often handicapped by professional cultures that avoid talk of dying or climates overly
focused on liability.
The skill and experience of palliative care, intensive care and geriatric specialists needs to be
recognised and shared. Leadership is required to promote intra- and inter- professional
reflection and dialogue regarding the limits of medicine. End of life education should be
included throughout medical training curricula. Communication skills need to be modelled
by experienced clinicians.
Care that appropriately addresses pain, agitation and distress should not be denied for fear
of the law. If the liability fears of health professionals are impacting practice, this needs to
be addressed through clarification of their position. If a lack of legal knowledge is an issue,
this should also be addressed in medical training curricula.
The role of the “person responsible” and the challenges of substitute decision-making
As discussed earlier, there are difficulties in relation to informed consent for future
decisions. It could be argued that a better way to deal with this scenario is via a substitute
decision maker. The current law allows the appointment of an enduring power of attorney
to act as your substitute in the event that you’re unable to make decisions for yourself.
Identification of a substitute decision maker is prompted by an understanding that there
may be a period of incapacity before death. It cannot be assumed that people are aware of
this possibility or the process followed by health professionals when it occurs. A person may
not have considered that near the end of life they may need another person to make
decisions on their behalf.
If a patient cannot consent to their own treatment, the medical practitioner may obtain
consent from the 'person responsible'. Someone formally appointed by the person or VCAT
will be considered the ‘person responsible’. If no formal appointment has been made, the
Clinical leaders need to drive conversations within the professions
regarding the limits of medicine. End of life education should be
included throughout medical training curricula. If perceived legal
vulnerability of health professionals is preventing the provision of
effective palliative care, their legal position requires clarification. The
law should support the delivery of effective palliative care.
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‘person responsible’ is deemed to be the person’s spouse or partner, primary carer or
nearest relative over the age of 18 (starting with the eldest child). (16)
It cannot be assumed that people understand the law in relation to capacity and consent to
medical treatment. This lack of legal literacy may be of particular consequence to the person
who does not have a spouse/partner, primary carer or near relative; or in circumstances
where that relationship feels unsafe or lacks trust. Advance care planning and power of
attorney conversations provide an important opportunity to identify any potential for
inappropriate or unwanted influence. Particular effort needs to be made to connect people
in these circumstances with information as to how to protect their best interests.
Even if a person’s preference is consistent with the legal default, it is unlikely that the
person or their spouse, primary carer or eldest child is fully cognisant of the ethical
demands of the role. Most people placed in this position want to be a “good” substitute
decision maker (SDM) who makes the “right” decisions. Some would say that is clearly
defined for them by the principle of substituted judgement – that is, a “good” substitute
decision maker makes the same decision the person would have made. This assumes the
SDM knows what decision the person would have made. It also sets a standard that makes
little if any allowance for the others ways an SDM may wish to be “good”. S/he may wish to
be a “good family member” who tries to keep family harmony by taking account of all of the
different views and the family’s capacity to provide or afford care. S/he may also try to be a
“good client” who cooperates with service staff and aligns with their preferences. S/he may
also strive to be a “good community member” who is mindful of finite resources and
pressures on the healthcare system. (17)
The complex reality of substitute decision making means SDMs are likely to need
considerable support to identify and advocate for the person’s wishes. It is common for
people to assume that those close to them ‘will just know’. This is challenged by
experienced SDMs who report that when the time comes you don’t “just know” and would
feel more confident if you had prior communication with the person regarding their
preferences. (18) This underscores the value of prompting and supporting end of life
conversations in communities and households.
The power of attorney appointment process presents an opportunity to discuss beliefs and
expectations. Do views differ regarding “quality of life” and life-prolonging treatment? ‘Do
you have strong views which you expect me to adhere to or are you happy for me to do the
Key to understanding the value of advance care planning is
knowledge regarding the law on capacity and consent. A
strategy is required to increase community literacy regarding
the definition of “person responsible”. The value of appointing
a medical enduring power of attorney (MEPOA) should be
widely publicised.
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best I can in the circumstances, weighing up all the factors?’ The discussion may also point
to other factors that influence capability. For older people with spouses/partners of a
similar age, does their own health status impact on their capacity to perform the SDM role?
‘Does the connection between us run so long and so deep that even when you’ve had
enough I still may not be ready to let go?’
Again, health literacy cannot be assumed. Information should be provided regarding the
kind of life-prolonging treatment options a SDM might be asked to consider, including which
ones require an instant decision and which ones may be thought about for longer.
Advance care planning conversations and the MEPOA appointment process clearly present
educational opportunities to better prepare SDMs for in-the-moment decision making.
(Consider whether this could be strengthened by a requirement to sign a statement of
acceptance, as is the case for an EPOA financial.) We would suggest a strong word of caution
against viewing advance care directives as the magic bullet. Whilst advance discussion and
preparation is helpful and should be strongly supported, the in-the-moment strains of
making decisions and caring for a dying loved one cannot be eliminated by planning.
Advance care directives should not be seen as removing the need for conversations and
SDM supports at the pointy end, both during the dying phase and beyond death.
Identification of the dying phase is a medical judgement. Clinicians are responsible for
presenting options in that frame. A person may need help putting a particular episode in
the context of the broader trajectory of the dying process. Again, the ethical nature of the
choice needs to be clear - it’s not a choice between ‘killing’ the person and ‘restoring
health’; the reversal of illness is not possible. When a treatment cannot be effective, that
needs to be made clear – this is not a judgement against the clinician (not skilled enough),
the patient (life not valuable enough) or the SDM (doesn’t care enough). (19) An ACD cannot
and should not take away the responsibility of medical teams to make a clinical assessment
and guide people through any treatment decisions. Training in completing advance care
directives should not take the place of training on how to discuss prognosis and goals of
treatment. It’s important that the ethical demands on the SDM are acknowledged.
Clinicians can lead supportive conversations with carers/families that shift away from a
notion of one ‘right’ course of action. For the SDM it’s not a case of ‘the right decision’; but
rather finding peace through engaging in a good decision-making process.
Substitute decision-making is ethically complex and can be a difficult
process. Carers and family members are not medical experts and need
information and guidance throughout the process, in particular regarding
the pros and cons of end of life interventions. They may need support to
identify and act in accordance with the person’s values or best interests.
More attention and resources need to be directed to supporting carers
and family members through the entire end of life trajectory.
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Conclusion
There are concerns in both the community and the professions regarding end of life care, in
particular the possibility of keeping people alive with little or no quality of life. In Australia,
we are in one sense privileged to have access to life saving treatment and technology. But
with that privilege comes responsibility, and the ethical dilemma of when “enough is
enough”. The government needs to support conversations within the professions and
community regarding dying and the role of medical intervention. Community members
need to understand why advance care planning conversations are important. This requires
an understanding that 1) you may lose capacity before dying 2) treatment isn’t always
successful or beneficial and 3) there could be decisions to be made on your behalf that are
difficult for those who care about you. Education to increase literacy in the community
regarding loss of capacity, the role of the “person responsible” and medical enduring power
of attorney needs to be prioritised.
The inclusion of end of life care throughout medical training curricula needs to also be a
priority. The capacity of health professionals to talk about prognosis, treatment intent, and
what matters to the patient is crucial. Goals and values need to be identified and reviewed
at key moments in the end of life trajectory.
If the person is no longer able to speak for themselves, these goals and values need to be
discussed with the carers/family. Making a decision on behalf of someone nearing end of
life can be ethically complex. Prior knowledge of what’s most important to the person
assists both the family and the care team at a difficult time. As the then Victorian
Department of Health clearly identified in 2014, it’s important to “have the conversation”. (20)
A single solution to a complex problem can be neat and plausible but insufficient. (21)
However useful an advance care directive may be, it is not a magic bullet. In many ways
more significant are the conversations that precede the document. Even then, prior
conversations cannot entirely eliminate the ethical demands of end of life decision-making.
Clinicians and carers/families need to be better prepared for in-the-moment conversations
and decisions. Professionals and substitute decision-makers need to be supported to make
respectful, compassionate decisions that keep the patient at the centre.
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Appendix A
Summary of key findings
Conversations need to be led within both the community and the health professions that
address fears regarding technology-driven ‘overtreatment’ and ageism-driven
‘undertreatment’.
Community members won’t engage in advance care planning conversations unless they
understand why it’s important. Increased knowledge regarding medical intervention during
the dying process, the right to ask questions and discuss options is key to this understanding.
The capacity to choose palliative care over acute or intensive intervention relies in part on
access to services. Appropriate investment in patient-centred palliative care needs to be
prioritised.
Patients should be asked about their goals for treatment. Health professionals need to assist
the person to translate their values and priorities into specific treatment decisions.
Definitions of a ‘life not worth living’ need to be explored, not assumed. The value of efforts
to build trust cannot be overestimated.
Clinical leaders need to drive conversations within the professions regarding the limits of
medicine. End of life education should be included throughout medical training curricula. If
perceived legal vulnerability of health professionals is preventing the provision of effective
palliative care, their legal position requires clarification. The law should support the delivery
of effective palliative care.
Key to understanding the value of advance care planning is knowledge regarding the law on
capacity and consent. A strategy is required to increase community literacy regarding the
definition of “person responsible”. The value of appointing an enduring power of attorney
(medical treatment) should be widely publicised.
When a treatment cannot be effective, that needs to be made clear – this is not a judgement
against the clinician (not skilled enough), the patient (life not valuable enough) or the
substitute decision-maker (doesn’t care enough).
Substitute decision-making is ethically complex and can be a difficult process. Carers and
family members are not medical experts and need information and guidance throughout the
process, in particular regarding the pros and cons of end of life interventions. They may need
support to identify and act in accordance with the person’s values or best interests. More
attention and resources need to be directed to supporting carers and family members
through the entire end of life trajectory.
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Appendix B
References
1 Swerissen, H and Duckett, S., (2014) ‘Dying Well’, Grattan Institute accessed via
http://grattan.edu.au/report/dying-well/
2 Hitchcock K., (2015) ‘Dear Life: On caring for the elderly’, Quarterly Essay Issue 57 (Mar),
accessed via https://www.quarterlyessay.com/essay/2015/03/dear-life
3 Swerissen, H and Duckett, S., (2014) as per 1
4 Dubler, N. N., (1995) ‘The doctor-proxy relationship: The neglected connection’, Kennedy Institute of Ethics Journal, 5(4) pp289-306
5 We are grateful for a discussion with Odette Waanders (Palliative Care Victoria) that
helped shape this idea.
6 State Government of Victoria, Better Health Channel, ‘Informed consent for medical
treatment’, information available at:
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Informed consent for
medical treatment, sourced 13/7/2015
7 Dolan P., (2007) ‘Finding a NICEr way to value health: From hypothetical preferences to
real experiences’, SMF Foresight, The Social Market Foundation accessed via
8 This idea was influenced by the work of Dr Atul Gawande, in particular:
Gawande A., (2014) ‘The Problem of Hubris’, The Reith Lectures, BBC London accessed
via http://www.bbc.co.uk/podcasts/series/reith
9 We are grateful to Dr Barbara Hayes (Northern Health) whose insights from clinical
experience influenced the inclusion of this point.
10 Sinclair C, Auret KA, Burgess A., (2013) ‘The balancing point: understanding uptake of advance directive forms in a rural Australian community’, BMJ Supportive & Palliative Care, 3, pp 358-365
11 Swerissen, H and Duckett, S., (2014) as per 1. Quote taken from National Health and
Hospitals Reform Commission (2009) A healthier future for all Australians, National
Health and Hospitals Reform Commission
12 Gillick,M.R., (published online April 29, 2015) ‘Re-engineering shared decisions-making’,
Journal of Medical Ethics, pp1-4
We are also grateful to Associate Professor Charlie Corke (Barwon Health) whose
insights from clinical experience influenced the inclusion of this idea.
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13 Borneman T., Irish T., Sidhu R. et al, (2014) ‘Death awareness, feelings of uncertainty,
and hope in advanced lung cancer patients: can they coexist?’, International Journal of
Palliative Nursing, 20(6), pp 271-277
14 Hayes, B., (2013) ‘Clinical model for ethical cardiopulmonary resuscitation decision-
making’, Internal Medicine Journal, 43(1), pp77-83
15 Dolan P., (2007) as per 7
16 Office of the Public Advocate (Vic), ‘Enduring power of attorney (medical treatment)’,
information available at http://www.publicadvocate.vic.gov.au/power-of-
